William N Southern1, Shadi Nahvi, Julia H Arnsten. 1. Department of Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA. wsouther@montefiore.org
Abstract
BACKGROUND: Approximately 500,000 patients are discharged from US hospitals against medical advice annually, but the associated risks are unknown. METHODS: We examined 148,810 discharges from an urban, academic health system between July 1, 2002 and June 30, 2008. Of these, 3544 (2.4%) were discharged against medical advice, and 80,536 (54.1%) were discharged home. We excluded inpatient deaths, transfers to other hospitals or nursing facilities or discharges with home care. Using adjusted and propensity score-matched analyses, we compared 30-day mortality, 30-day readmission, and length of stay between discharges against medical advice and planned discharges. RESULTS: Discharge against medical advice was associated with higher mortality than planned discharge, after adjustment (odds ratio [OR](adj) 2.05; 95% confidence interval [CI], 1.48-2.86), and in propensity-matched analysis (OR(matched) 2.46; 95% CI, 1.29-4.68). Discharge against medical advice also was associated with higher 30-day readmission after adjustment (OR(adj) 1.84; 95% CI, 1.69-2.01), and in propensity-matched analysis (OR(matched) 1.65; 95% CI, 1.46-1.87). Finally, discharges against medical advice had shorter lengths of stay than matched planned discharges (3.37 vs 4.16 days, P <.001). CONCLUSIONS: Discharge against medical advice is associated with increased risk for mortality and readmission. In addition, discharges against medical advice have shorter lengths of stay than matched planned discharges, suggesting that the increased risks associated with discharge against medical advice are attributable to premature discharge.
BACKGROUND: Approximately 500,000 patients are discharged from US hospitals against medical advice annually, but the associated risks are unknown. METHODS: We examined 148,810 discharges from an urban, academic health system between July 1, 2002 and June 30, 2008. Of these, 3544 (2.4%) were discharged against medical advice, and 80,536 (54.1%) were discharged home. We excluded inpatient deaths, transfers to other hospitals or nursing facilities or discharges with home care. Using adjusted and propensity score-matched analyses, we compared 30-day mortality, 30-day readmission, and length of stay between discharges against medical advice and planned discharges. RESULTS: Discharge against medical advice was associated with higher mortality than planned discharge, after adjustment (odds ratio [OR](adj) 2.05; 95% confidence interval [CI], 1.48-2.86), and in propensity-matched analysis (OR(matched) 2.46; 95% CI, 1.29-4.68). Discharge against medical advice also was associated with higher 30-day readmission after adjustment (OR(adj) 1.84; 95% CI, 1.69-2.01), and in propensity-matched analysis (OR(matched) 1.65; 95% CI, 1.46-1.87). Finally, discharges against medical advice had shorter lengths of stay than matched planned discharges (3.37 vs 4.16 days, P <.001). CONCLUSIONS: Discharge against medical advice is associated with increased risk for mortality and readmission. In addition, discharges against medical advice have shorter lengths of stay than matched planned discharges, suggesting that the increased risks associated with discharge against medical advice are attributable to premature discharge.
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